Effect of Coronavirus Infection on Fasting Blood Glucose, Kidney Function, and Electrolytes in COVID-19 Patients in the Zawia Region, Western Libya

Research Article | DOI: https://doi.org/10.31579/2766-2314/043

Effect of Coronavirus Infection on Fasting Blood Glucose, Kidney Function, and Electrolytes in COVID-19 Patients in the Zawia Region, Western Libya

  • Azab Elsayed Azab 1*
  • Khaled Alawaini 2
  • Ashraf Mohamed Albakoush 3
  • Nouri Kushlaf 4
  • Sadig Abdalla 5
  • Saja Mohamed 5

1 Department of Physiology, Faculty of Medicine, Sabratha University, Libya. 
2 PhD Researcher at Biochemistry, Memorial University, Canada. 
3 Department of Medical Laboratory, Faculty of Medical Technology, Sabratha University, Surman, Libya. 
4 Faculty of Science, Zawia University, Western Libya. 
5 Researcher at National Center for Disease Control, Libya

*Corresponding Author: Azab Elsayed Azab, Department of Physiology, Faculty of Medicine, Sabratha University, Libya.

Citation: Azab E. Azab, Alawaini K., Kushlaf N., Ashraf M. Albakoush, Abdalla S., and Mohamed S. (2021) Effect of Coronavirus Infection on Fasting Blood Glucose, Kidney Function, and Electrolytes in COVID-19 Patients in the Zawia Region, Western Libya. J, Biotechnology and Bioprocessing 2(4); DOI: 10.31579/2766-2314/043

Copyright: © 2021, Azab Elsayed Azab, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 14 May 2021 | Accepted: 20 May 2021 | Published: 28 May 2021

Keywords: COVID-19, coronavirus, fasting blood glucose, kidney function, electrolytes, zawia region, western libya

Abstract

Background: Coronavirus disease 19 (COVID-19) is a pandemic infectious disease caused by the novel coronavirus. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). It is an aggressive virus that spread worldwide and is a systemic disease involving multiple systems, including respiratory, cardiovascular, gastrointestinal, hematopoietic, neurological, immune, and urinogenital systems.

Objectives: The present study aimed to evaluate the alteration in fasting blood glucose, serum urea, creatinine, Na+, K+, and Cl- levels among COVID-19 patients in the Zawia region, Western Libya.

Materials and Methods: 416 confirmed COVID-19 patients hospitalized in the Isolation Centre located in Zawia city, Libya. From the 1st May 2020 to the 30th March 2021, were enrolled in this prospective study.  Covid-19 patients were defined as positive cases after the detection of SARS-CoV-2 RNA in oro-nasopharyngeal swab samples. Demographic data were extracted from electronic medical records and patient files. Also, 30 healthy individuals without any chronic disease or respiratory symptoms were recruited for the control group. Blood samples were collected via vein puncture for estimating biochemical parameters (fasting blood glucose, serum urea, creatinine, Na+, K+, and Cl- concentrations). The statistical significance of differences between groups was evaluated with the Mann- Whitney (U test). Associations between different parameters were evaluated with the Spearman's test.

Results: The results showed that coronavirus infection induced a significant increase in fasting blood glucose, serum urea, and creatinine concentrations. Infections also induced a decrease in serum sodium ion concentration, compared with healthy individuals. Seventy-six percent of corona virus-infected patients had hyperglycemia. Similarly, high levels of serum urea, creatinine, Cl-, Na+, and K+ were found in 40.9%, 39.9%, 27.9%, 8.9% and 6.5% of patients, respectively. Hyponatraemia, hypokalaemia, and hypochloremia were found in 35.5%, 13.7%, and 12.9% of patients. There were recorded a significant positive association between fasting blood glucose and serum urea, creatinine, and K+ concentration, between serum urea concentration and serum creatinine, K+, and Cl- concentrations, between serum creatinine and K+, and Cl- concentrations, and between serum Na+ and Cl- concentration, and a significant negative association between fasting blood glucose and serum Na+ and Cl- concentrations and between serum K+ and Na+ concentrations.

Conclusion: It can be concluded that coronavirus infections induced increases in fasting blood glucose, serum urea, and creatinine, and a decrease in Na+ concentrations. There was a significant association between different parameters. These biochemical changes may help the clinicians to understand COVID-19 better and provide more clinical treatment options and prevent the serious complications of the disease. Thus, clinicians should pay special attention to fasting blood glucose, kidney function and electrolyte status of COVID-19 patients. Changes in fasting blood glucose, kidney function, and electrolyte levels can be a good indicator of disease progression.

Introduction

Coronavirus disease 19 (COVID-19) is a pandemic infectious disease caused by the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Old age and comorbidities, including diabetes, are associated with a more severe course and a higher fatality rate [1]. Since March 6, 2021, over 115 million cases have been reported globally, with more than 2 million deaths [2, 3]. The global pandemic secondary to the SARS-CoV-2 is leading to unprecedented global morbidity and mortality. Common symptoms include cough (50%), fever (43% of patients), and dyspnea (29%) but other features such as diarrhea (19%), myalgia (36%), hypogeusia, and anosmia (10%) are also common [4, 5].

The coronavirus disease 2019 is an aggressive virus that spread worldwide and caused a pandemic infection. It is a systemic disease involving multiple systems, including the respiratory, cardiovascular, gastrointestinal, hematopoietic, neurological, and immune systems. The urinogenital system is also affected by the disease and its complications [3, 6-8].

Hyperglycemia can occur in diabetic and non-diabetic patients hospitalized for COVID-19 and is common among acute hospital admissions and critically ill patients, encompassing those with no previous history of hyperglycemia [9-11].Also,Wang et al. [12] indicated that the level of fasting blood glucose at the time of admission is a significant prognostic factor for COVID-19. The meta-analysis carried out by Chen et al. [13] provides evidence that severe COVID-19 is associated with increased blood glucose. This finding highlights the need to effectively monitor blood glucose to improve prognosis in patients infected with COVID-19. Also, previous studies were suggested that uncontrolled hyperglycemia causes an increase in length of hospitalization and mortality caused by SARS-CoV-2 infection [14, 15].

The kidneys have a wide range of roles, including urine formation, hormone secretion, blood pressure regulation, acid-base balance, and osmolality regulation, so their normal function is essential [3, 16]. They play an essential role in maintaining fluid and electrolyte balance in the body. Disturbance to their functioning can lead to an imbalance of fluid and electrolytes. Impaired fluid and electrolyte balance can be dangerous if left unchecked [3]. Recently, the novel COVID-19 has attracted the attention of scientists where it has a high mortality rate among older adults and individuals suffering from chronic diseases, such as chronic kidney diseases [17]. Recent reports indicate that renal impairment is more common in patients with COVID-19 [3, 18-20]. In previous reports, the incidence of acute kidney injury (AKI) in patients with COVID-19 ranged widely from 0 to 36.6% [21-25]. Coronavirus enters the cell by binding to the angiotensin-converting enzyme 2 (ACE2) receptors [3, 26, 27]. Due to the high level of these receptors in kidney cells, the kidneys are not immune to coronavirus invasion [3]. The kidney's involvement with pathogens can disrupt a wide range of body mechanisms and cause many problems such as fluid and electrolyte imbalances. Therefore, monitoring renal function can prevent severe complications in patients involved with COVID-19 and operates an essential role in reducing mortality [3, 28].

The most common renal complication in COVID-19 hospitalized patients is electrolyte disorders [3, 28-30]. Various clinical and histopathological studies have demonstrated evidence of hypokalaemia, hyponatraemia, the syndrome of inappropriate antidiuretic hormone (SIADH), incomplete Fanconi syndrome, and tubulopathy in patients with SARS-CoV-2 infection [5]. Studies on COVID-19 confirm electrolyte disturbances in patients, including sodium, potassium, chlorine, and calcium imbalances [3, 19, 31]. Also, the results of Sarvazad et al. [15] study showed that hyponatraemia was more common in outpatients than in severe patients. However, all cases of hypernatraemia were observed in patients with severe disease. Electrolyte imbalances lead to cardiovascular and renal involvement [15, 32]. Because many electrolyte disorders have significant consequences to help identify the pathophysiological mechanisms underlying COVID-19 and patient management, they can provide new therapeutic opportunities [3, 29].

The present study aimed to evaluate the alteration in fasting blood glucose, serum urea, creatinine, Na+, K+, and Cl- levels among COVID-19 patients in the Zawia region, Western Libya.

Materials and Methods

416 confirmed COVID-19 patients hospitalized in the Isolation Centre located in Zawia city, Libya, from the 1st May 2020 to the 30th March 2021, were enrolled in this prospective study. Covid-19 patients were defined as positive cases after the detection of SARS-CoV-2 RNA in oro-nasopharyngeal swab samples. This study was approved by the Research and Ethical Committee of the Faculty of Medical Technology, Sabratha University. Demographic data were extracted from electronic medical records and patient files. Also, 30 healthy individuals without any chronic disease or respiratory symptoms were recruited for the control group. Blood samples were collected by vein puncture 5 ml of venous blood withdrawn from each participant in the study by using disposable syringes under an aseptic technique; they then transferred to a sterile tube for estimating biochemical parameters.

Fasting blood glucose, serum urea, creatinine, Na+, K+, and Cl- concentrations were determined using automated COBAS E411 and INTEGRA 400 machines in the Zawia Isolation Centre laboratory.

Statistical analysis

Continuous variables were presented as medians (interquartile range [IQR]); categorical variables were presented as counts (%). The data were analyzed using Graph Pad Prism software version .7. The Kolmogorov-Smirnov test was used to assess the normality of the distribution of continuous variables. The statistical significance of differences between COVID-19 patients and healthy individuals groups was evaluated with the Mann-Whitney (U test). Associations between the different parameters were evaluated with the Spearman's test. A P-value of <0>was used to establish statistical significance.

Results

Four hundred and sixteen confirmed COVID-19 patients, 236 males (56.7%) and 180 females (43.3%) were included in the current study (Figure. 1). 

Figure 1: Distribution of patients according to gender.

The results in table.1 and figure .2 show that patients with COVID-19 had a significant (P< 0>

The results in table.2 and figure.3 show the percentages of corona virus infected patients with normoglycemia [(70-115) mg/dl] were 22.6%, hypoglycemia (<70>115 mg/dl) were 76%.

Figure.2: Median (IQR) of fasting blood glucose in controls and COVID-19 patients.
Figure. 3: Percentage of COVID-19 patients according to the levels of fasting blood glucose 

The results in table.1 and figure .4 show that patients with COVID-19 had a significant (P< 0>

The percentages of corona virus infected patients with normal serum urea concentration (≤40 mg/dl) were 59.1%, and with uremia (>40 mg/dl) were 40.9% (Table. 2 & Figure.5).

Figure.4: Median (IQR) of serum urea concentration in controls and COVID-19 patients
Figure. 5: Percentage of COVID-19 patients according to serum urea concentration. 

Data in table.1 and figure .6 show that patients with COVID-19 had a significant (P= 0.0223) increase in serum creatinine concentration [(median (IQR) mg/dl], 1 (0.8-1.7) compared with the healthy individuals 0.9 (0.8-1.1).

The percentages of corona virus infected patients with normal serum creatinine concentration (≤1.2 mg/dl) were 60.1%, and with high serum creatinine concentration (>1.2 mg/dl) were 39.9% (Table. 2 & Figure. 7).

Figure.6: Median (IQR) of serum creatinine concentration in controls and COVID-19 Patients
Figure. 7: Percentage of COVID-19 patients according to serum creatinine concentration. 
IQR:Interquartile range, ns: none significant difference compared with the controls, (*) significant difference compare with the controls at (P<0.05), (***) significant difference compared with the controls at (P<0.001).
Table 1: Median (IQR) of fasting blood glucose, serum urea, creatinine, Na+, K+, and Cl- concentrations in control and COVID-19 patients
 

Data in table.1 and figure .8 show that patients with COVID-19 had a none significant (P= 0.5582) changes in serum potassium ion concentration [(median (IQR) mEq/L)], 4.2 (3.8-4.7) compared with the healthy individuals 4.3 (3.88-4.70).

The percentages of corona virus infected patients with hypokalaemia (<3>5.5 mEq/L) were 6.5% (Table. 2 & Figure. 9).

Figure.8: Median (IQR) of Serum potassium ion concentration in controls and COVID-19 Patients
Figure. 9: Percentage of COVID-19 patients according to serum potassium ion concentration. 

Data in table.1 and figure .10 show that patients with COVID-19 had a significant (P<0>

The percentages of corona virus infected patients with hyponatraemia (<135mEq>145mEq/L) were 8.9% (Table. 2 & Figure. 11).

Figure.10: Median (IQR) of serum sodium ion concentration in controls and COVID-19 Patients
Figure. 11: Percentage of COVID-19 patients according to   serum sodium ion concentration.

Data in table.1 and figure .12 show that patients with COVID-19 had a none significant (P= 0.4771) changes in serum chloride ion concentration [(median (IQR) mEq/L)], 103 (100-107) compared with the healthy individuals 101.5 (99.7-105.5).

The percentages of corona virus infected patients with hypochloremia (<98mEq>106mEq/L) were 27.9% (Table. 2 & Figure. 13).

Figure.12: Median (IQR) of serum chloride ion concentration in controls and COVID-19 patients
Figure. 13: Percentage of COVID-19 patients according to serum chloride ion concentration.
Table 2: Frequency and percentage of coronavirus infected patients for fasting blood glucose, serum urea, creatinine, Potassium ion, sodium ion, and chloride ion concentrations.

Table 3 shows a significant positive association between fasting blood glucose& serum urea, creatinine, and K+ concentration, between serum urea concentration& serum creatinine, K+, and Cl- concentrations, between serum creatinine and K+, and Cl- concentrations, and between serum Na+ and Cl- concentration. The same table show a significant negative association between fasting blood glucose and serum Na+ and Cl- concentrations and between serum K+ and Na+ concentrations, and a none significant association between serum urea and Na+ concentrations, between creatinine and Na+ concentrations, and between serum K+ and Cl- concentrations. 

ns: none significant association, *: significant association at (P<0.05), **: significant association at (P<0.01),                 ***: significant association at (P<0.001).
Table 3: Association between fasting blood glucose, serum urea, creatinine, K+, Na+, and Cl- levels in COVID-19 patients.
 

Discussion

Hyperglycemia can result from related conditions such as severe sepsis, systemic inflammatory response syndrome, and traumatic brain injury. The initial response to these conditions is an increase in cytokines, accompanied by high levels of blood glucose. It has been shown that there is a association between glucose blood levels and morbidity/mortality of patients [15, 33, 34]. McGuinness [35] reported that infection leads to profound alterations in whole-body metabolism, including protein, glucose, and fat. Also, people with diabetes have higher risks of various infections [36]. Therefore, these diabetic patients might be at increased risk of COVID-19 and have a poorer prognosis [36]. Studies of risk factors for the mortality and morbidity of community-acquired pneumonia, SARS, and Middle East respiratory syndrome have shown that hyperglycemia and/or diabetes are involved [15, 37].

The present study showed that coronavirus infection induced a significant increase in fasting blood glucose levels in patients. The percentages of corona virus-infected patients with hyperglycemia were 76%. These results agree with the results of the previous studies [11, 12, 14, 15, 28]. Sarvazad et al. [15] found that from all included COVID-19 patients, 49.1% hyperglycemia were observed. There was a statistically significant difference between the outpatient and ICU groups in terms of FASTING BLOOD GLUCOSE (p < 0>Sarduet al. [11]recorded that 57.6% of COVID-19 patients were normoglycemic, and 42.4% were hyperglycemic. At baseline, IL-6 and D-dimer levels were significantly higher in the hyperglycemic group than in the normoglycemic group (P < 0>et al. [42] reported that the pancreas could be the target of coronavirus attack since SARS-CoV was detected in the pancreas. Also, Yang et al. [41] found that SARS-CoV damaged the endocrine part of the pancreas, indicating that SARS-CoV may cause acute insulin-dependent diabetes mellitus.

The prevalence of mild to moderate chronic kidney disease (CKD) in older patients with established diabetes (aged ≥65 years) ranges from 35% to 40% (38, 43]. CKD is associated with an increased risk for pneumonia and pneumonia-related mortality [38, 44, 45]. In severely affected COVID-19 patients, associated hypoxaemia, heart involvement (e.g. acute myocardial infarction, myocarditis, shock, exacerbation of heart failure, and arrhythmia), cardiovascular instability, and endothelial injury may also contribute to kidney injury, in what is considered a brand new cardiorenal syndrome [7, 46]. In addition to direct virus infection, kidney injury may result from the systemic response to infection or damage to other organs. While most commonly manifested as acute kidney injury, other forms of kidney injury and electrolyte abnormalities have been described [7]. Recent studies have shown that the prevalence of renal failure upon admission and the progression of acute kidney injury during hospitalization of COVID-19 patients was high, which was associated with increased in patient mortality [17, 21]. In COVID-19, the kidney and GIT are at risk, and a variety of complications have been reported that are very common [3, 47, 48]. Fluid and electrolyte disturbances are complications of kidney and GIT injuries in COVID-19 patients. Fluid and electrolyte disturbances can lead to many problems and even death. As such, clinicians should monitor fluid and electrolyte balance in COVID-19 patients, especially in patients under intensive care who are at elevated risk of fluid and electrolyte disturbance [3, 49].

The results of the current study showed that coronavirus infection induced a significant increase in serum urea and creatinine concentrations, and a decrease in serum Na+ concentration in COVID-19 patients. The percentages of coronavirus-infected patients with high levels of serum urea, and creatinine were 40.9%, and 39.9%, respectively, and with hyponatraemia, hypokalaemia, and hypochloremia were 35.5%, 13.7%& 12.9%, respectively. Our results are similar to previous studies [7, 15, 17, 19, 21, 29, 31, 50-54]. Sarvazad et al. [15] found that from all included COVID-19 patients, 38% hyponatremia, and 7.3% hypokalemia were observed. Unlike the mean of age and the level of K+, there was a statistically significant difference between the outpatient and ICU groups in terms of Na+ (p<0>Moreno et al. [52] described 306 COVID-19 patients in Spain with potassium measured in the first 72 h of admission. They found that hypokalemia was independently associated with requiring invasive mechanical ventilation, but mortality was not influenced by low potassium. De Carvalho  et al. [54] carried out a case-control study in three hospitals in France, including adult patients visiting the emergency department (ED) (≥ 18 years old). A total of 594 ED case-patients in whom infection with COVID-19 was confirmed were matched to 594 non-COVID-19 ED patients (controls) from the same period, according to sex and age. Hyponatremia was defined by sodium of less than 135 mmol/L (reference range 135–145 mmol/L), hypokalemia by potassium of less than 3.5 mmol/L (reference range 3.5–5.0 mmol/L), and hypochloremia by chloride of less than 95 mmol/L (reference range 98–108 mmol/L). Hyponatremia was more common among case-patients than among controls, as was hypokalemia and hypochloremia [54]. In a study including one hundred seventy-five COVID-19 patients, 18% were classified as having severe hypokalemia, 37% had hypokalemia, and 46% had normokalemia [55].

Carriazo et al. [7]  reported that hyponatraemia is common in COVID-19 patients. The cause appears to be outside the kidneys as the occurrence of the syndrome of inappropriate antidiuretic hormone has been well characterized by Ravioli et al. [56]. Also, hyponatraemia was found in 8% of patients with community-acquired pneumonia, with nearly half of the cases having SIADH [57].  Also, hyponatraemia has been reported in COVID-19 [15, 19, 31, 53, 58]. In a retrospective study conducted by Zhang et al. [53], the association between hyponatraemia and the severity of COVID-19 was considered. In a review study of electrolyte imbalances in patients with COVID-19, five studies were identified with a total of 1415 participants, indicating a relationship between decreased blood sodium and disease severity [15, 29]. Pourfridoni et al. [3] reported that the coronavirus infects the host by binding to the ACE2 receptors. Due to the presence of ACE2 receptors in the kidneys and gastrointestinal tract (GIT), kidneys, and GIT, damage arising from the virus can be seen in patients and can cause acute kidney injury (AKI) and digestive problems for the patient. Increased ACE2 leading to direct viral invasion along with hypercoagulation could explain the high risk of acute kidney injury in patients with COVID-19 even without the preexisting renal disease [38]. As one of the expression sites of the ACE2 receptor is in the proximal tubule [15, 59], hyponatraemia can occur due to increased expression of the ACE2 receptor in the proximal tubule. In an individual with severe hyponatraemia, it was shown that SARS-CoV-2 causes a syndrome of inappropriate secretion of antidiuretic hormone and manifestations of hyponatremia [15, 60].

People with COVID-19, who are taking drugs that inhibit the renin-angiotensin-aldosterone (RAS), reduce the production of aldosterone, and this can cause fluid and electrolytes imbalances in the patient. Mineralocorticoid receptor (MR), which has different types, is expressed in various tissues, including the kidneys, GI tract, central nervous system (CNS), and heart, and is known as the aldosterone receptor. Activation of MR leads to changes in the concentration of ions (such as sodium and potassium). These changes are necessary to maintain the balance of fluid and electrolytes in the body. Still, due to MR’s presence in the large intestine [3, 61-63], if the aldosterone pathway is disrupted, the absorption and secretion of ions in the colon are disrupted, and fluid and electrolyte imbalance occurs. Hypokalemia, a complication of COVID-19, can exacerbate acute respiratory distress syndrome (ARDS) and increase the risk of heart injuries in patients [3, 29]. The number of ions, including sodium and potassium, is a significant indicator in COVID-19 patients [3, 49]. In some people with SARS-CoV-2 infection, the syndrome of inappropriate antidiuretic hormone secretion (SIADH) has been reported [3, 5], leading to disturbances in fluid and electrolytes [3].

Hypokalaemia exacerbates acute respiratory distress syndrome and acute cardiac injury, which are common complications in COVID-19, especially in patients with underlying lung or heart disease. Hypokalaemia also provides a pathophysiologic clue; SARS-CoV-2 binds to its host receptor, ACE2 and likely reduces ACE2 expression, leading to increased angiotensin II, which can cause increased potassium excretion by the kidneys, ultimately leading to hypokalaemia (29, 55, 64]. Increased plasma angiotensin II concentration has been described in patients with COVID-19, possibly acting as a mediator of acute lung injury, as earlier confirmed in SARS-CoV animal models [29, 64, 65].  A second potential contributor to hypokalaemia and other electrolyte imbalance in some COVID-19 patients may be gastrointestinal losses, with diarrhea and nausea present in as many as 34.0% and 3.9% of cases, respectively [29, 66].

Conclusion

It can be concluded that coronavirus infections induced increases in fasting blood glucose, serum urea, and creatinine, and a decrease in Na+ concentrations. There was a significant association between different parameters. These biochemical changes may help the clinicians to understand COVID-19 better and provide more clinical treatment options and prevent the serious complications of the disease. So, clinicians should pay special attention to FASTING BLOOD GLUCOSE, kidney function and electrolyte status of COVID-19 patients. Changes in FASTING BLOOD GLUCOSE, kidney function, and electrolyte levels can be a good indicator of disease progression. 

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad